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http://dx.doi.org/10.2147/PRBM.S10380

Affective psychotherapy in post-traumatic reactions guided by affective neuroscience: memory reconsolidation and play

Göran Högberg1,2

Davide Nardo3

Tore Hällström4,5

Marco Pagani6,7

1Department of women’s and Children’s Health, Child and Adolescent Psychiatric Unit, Astrid Lindgren Children’s Hospital, Karolinska institutet, Stockholm, Sweden; 2BUP Huddinge Child and Adolescent Psychiatry, Stockholm, Sweden; 3Neuroimaging Laboratory, Santa Lucia Foundation, Rome, italy; 4Department of Clinical Neuroscience, Section for Psychiatry/Huddinge, Karolinska institutet, Stockholm, Sweden; 5Department of Neuroscience, Section of Psychiatry and Neurochemistry, Unit for Neuropsychiatric epidemiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 6Department of Nuclear Medicine, Karolinska Hospital, Stockholm, Sweden; 7institute of Cognitive Sciences and Technologies, CNR, Rome, italy

Correspondence: Göran Högberg BUP Huddinge, Paradistorg 4, 141 47 Huddinge, Sweden Tel +46 8 51452900 Fax +46 8 51452905 email gor.hogberg@gmail.com

Abstract: This paper reviews the affective neuroscience dealing with the effects of traumatic

events. We give an overview of the normal fear reactions, the pathological fear reaction, and the

character of emotional episodic memories. We find that both emotions and emotional memories

are a tripartite unit of sensory information, autonomic reaction, and motor impulse (the PRM

complex). We propose that emotions and movements are part and parcel of the same complex.

This is our main finding from the review of affective neuroscience, and from here we focus on

psychotherapy with post-trauma reactions. The finding of the process of memory reconsolidation

opens up a new treatment approach: affective psychotherapy focused on reconsolidation. The

meaning of reconsolidation is that an emotional memory, when retrieved and being active, will

rest in a labile form, amenable to change, for a brief period of time, until it reconsolidates in

the memory. This leads us to the conclusion that emotions, affects, must be evoked during the

treatment session and that positive emotion must come first, because safety must be part of the

new memories. In the proposed protocol of affective psychotherapy based on reconsolidation

the emotional episodic memory is relived in a safe and positive setting, focused in turn on the

sensory experience, the autonomic reaction, and the motor impulse. Then it is followed by a

fantasy of a different positive version of the same event. All in all treatment should provide a

series of new memories without fear related to the original event. With the focus on the motor

program, and the actions, there is a natural link to art therapy and to the mode of play, which

can rehearse and fantasize new positive actions.

Keywords: post-traumatic, PTSD, affective neuroscience, memory reconsolidation, psycho-

therapy, play

AimIn this article the aim is to create an outline of the findings from neurocognitive sci-

ence of dysfunctional reactions in the aftermath of traumatic experiences. From this

contour we suggest a protocol of treatment principles.

Trauma across diagnoses – trauma spectrum disordersOver the years many trauma-related diagnoses have emerged in psychiatry, several

of of which were related to extreme experiences such as war and termed shellshock,

war neurosis, traumatic neurosis, and disordered action of the heart. Oppenheim´s

term, from 1892, traumatic neurosis, opens the descriptions even for traumas of

civilian origin.1 With the advent of the DSM-III in 1980, epidemiological studies

were enabled by a common definition of a post-traumatic stress disorder (PTSD).

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Högberg et al

The National Comorbidity Survey in the United States

reported a lifetime prevalence rate of 10.4% in women and

5% in men.2 The lifetime prevalence of PTSD in Sweden is

estimated to be 7.4% for women and 3.6% for men.3

Trauma reactions are an important part of the general

outpatient psychiatry. In a survey of an outpatient clinic,

conducted in a part of Stockholm in which live many immi-

grants, 77% of patients had been exposed to several traumas.

The prevalence of PTSD was estimated to be 69% within the

Iranian, 59% within the Arabic, 53% within the Turkish, and

29% within the Swedish patient cohorts.4

Traumatic experiences followed by negative emotional

memories are related to depression: in a meta-analysis with

14,240 subjects there was a strong correlation between child-

hood adverse experiences and depression.5 The symptoms of

patients with severe difficulties of mood regulation and with

increased suicidal tendencies have been described to result

from previous traumas such as rape and abuse.6

Trauma tends also to be a background factor in psychotic

manifestations such as hallucinations.7 The inner experience

of the psychotic episode as well as the encounter with the

health-care and law-enforcement systems during the psychotic

episode may itself be a traumatic event with post-traumatic

sequelae.8 A factor contributing to psychotic symptoms is

strong anxiety, and progressive relaxation was useful for

dampening these symptoms.9 Another clinically important

reaction is trauma-related dissociative psychosis, which can be

characterized as a long permanent flashback, the patient reliv-

ing the traumatic preceding event in a symbolic disguise.10

The Adverse Childhood Experiences (ACE) study includ-

ing 17,337 subjects disclosed a strong relationship between

adverse childhood experiences and depression, suicide

attempts, alcoholism, drug abuse, and other negative health

outcomes.11 Traumatic experiences in childhood with longer

duration – as in cases with trauma and neglect – impair

self-regulation function such as mood regulation and constancy

in relations. This is described in new diagnoses such as “com-

plex PTSD” and “developmental trauma disorder”.12

The wide array of psychopathology related to traumatic

experiences and fear reactions that go under the heading of

trauma spectrum disorders provide the common ground for

many of the concomitant diagnoses in severe post-trauma

reactions.

Affective neuroscience and psychotherapeutic optionsThe study of emotions is an expanding field in neurocogni-

tive science. Both clinical and preclinical studies shed light

on the networks in the brain that are involved in trauma

reactions. Rodent models of stress, mimicking human fear

reactions, have been proposed. With humans, technolo-

gies capable of registering brain activity are rapidly being

developed. Electrical activity of the brain’s cortex can be

recorded using electroencephalography (EEG). Single photon

emission computerized tomography (SPECT), positron emis-

sion tomography (PET), and functional magnetic resonance

imaging (fMRI) are techniques capable of detecting relative

changes in electric activity/blood flow/oxygenation, respec-

tively, which are indicative of differences in regional brain

activity.13 The purpose of this paper is to extract the main

findings relating to emotional memory and effects of treat-

ment, and to tentatively suggest psychotherapeutic options,

following findings of affective neuroscience.

Fear reactions in episodic memoryFearful experiences are not automatically followed by a

subsequent pathological fear reaction. Normally, a traumatic

event is followed by an acute stress reaction that naturally

subsides within a month. The organism learns a no-fear

signal; the danger is over and the fear reaction is no longer

functional.14 When a pathological post-traumatic reaction

develops, the fear reaction is preserved and the organism

establishes a state of alarm and action-preparedness. This

heightened fear reactivity can manifest itself when a person is

quiet and trying to relax, for instance when going to bed and

during sleep, having gained an automatic quality of being a

default state. Sensory experiences associated with the original

traumatic situation can trigger the fear reaction into more

explicit states of pathological fear such as anxiety, panic,

unrest, and destructive actions. At the bottom lies the original

traumatic situation, but what then follows has to do with the

way the organism is processing that experience, that is, it

has to do with memory. Memory is a popular concept with

many aspects. The memory of the past experiences has many

qualifying terms, such as declarative, narrative, explicit, and

personal memory, but here we choose the broader concept

of episodic memory since this can also include sensory and

hidden elements that are not declarative or explicit, but

nevertheless part of the trauma episode.

Emotion and memoryThe organism is set to act in relation to the environment;

thus emotions can be conceptualized as guiding mental

states to implement appropriate motor programs. Emotions

are like a coloring of the memory of an event, basically

divided into positive or negative. This division has been

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Affective neuroscience and psychotherapy in trauma reactions

described as two distinct reaction patterns.15 With posi-

tive emotions there is an appetite and approach behavior

implicated. With negative emotions – such as fear and

anger – an active escape from danger, withdrawal, or

withdrawal after attack occurs. This is in accordance with

a multidimensional definition of feelings by Osgood et al16

involving valence, intensity, and level of control. The epi-

sodic memory activates networks with reciprocal pathways

linking medial temporal lobe, prefrontal cortex, thalamus,

hypothalamus, brainstem, striatum, anterior cingulated,

sensorimotor areas, and cerebellum. In the ensuing text we

give examples thereof.

When positive emotions are evoked by a script, there is an

increased activity in the anterior cingulated, anterior temporal

cortex as well as the ventral globus pallidus, indicating autono-

mous arousal as well as action preparation.17 The viewing of

both negative and positive movies, as well as recall-generated

emotions, were shown to be associated with increased activity

in the medial prefrontal cortex and thalamus.18 The early visual

induction of feelings activates somatosensory systems.19

Sabatinelli et al20 found that both negative and positive emo-

tions evoked by scripts lead to increased activation in areas

involved with preparatory motor action.

It seems that memory is not located in a certain area of

the brain but is rather a temporal coordination of the reac-

tivation of sensory, autonomic-related, and motor areas that

were activated at the event of imprinting. To quote Damasio

“This proposal rejects a single anatomical site for the inte-

gration of memory and motor processes and a single store

for the meaning of entities of events. Meaning is reached

by time-locked multiregional retroactivation of widespread

fragment records”.21

Estimations of the future is also a part of the memory

function, being memories of fantasies and calculations done

in order to have understanding and control of what may be

arriving ahead in time.

The episodic memory–perception, reaction, and motor impulses (a PRM-complex)The definition of memory by Domjan and Burkhard,22

“A theoretical term used to determine instances in which a

subject’s current behavior is determined by some aspects of

his previous experience”, leads towards the point of memory

and action. The psychotherapy researcher Wolpe23 argued

that an emotional picture could be seen as a neural event

that partly replicates the previous event itself in its aspects

of sensations and impulses. Lang24 developed a theory

pertaining to the emotional picture where he describes

the emotional image as an action sequence with a series

of propositions of sensory experiences and action alterna-

tives. Thus, there also is an activation of motor impulses.

Both the premotor cerebral cortex and the cerebellum are

activated in imagined movement.25 The cerebellum engages

in the reassignment of motor response.26 The autonomic

regulation and its body representation in emotions are

associated with the anterior cingulate and the insula.27,28 We

can conceive episodic memory as an organized tripartite

complex with perception, reaction, and motor impulse (the

PRM-complex).

Consciousness is a balance between situational input

and internal input with remnants from previous experiences.

The thalamus involves systems for sensory information and

sensorimotor integration and can be activated by external,

as well as by internal stimuli.29 The episodic memory is not

a slide show with one distinct episode presented at a time

but rather like the northern lights, ever waxing and waning

associative networks, some aspects being in the front, soon

to be replaced by another set of combinations.30 Considering

this, it has also to be understood that episodic memories are

always having at least some taint of emotion. Moreover, epi-

sodic memory can present itself in parts, showing fragments

in various sensory and autonomic modalities. This means that

episodic memory might appear as an inner vision, a sound,

or just a hint – a brief sensation in the belly or a strong pain

in the chest.

The hemispheric lateralization of emotional memoriesA consistent and intriguing finding in affective neuroscience

has been the lateralization of emotions. This field started with

the findings by Jules Bernard Luys31 of emotional responses

in hemiplegic patients, left hemiplegic patients being more

emotional and anxious and right hemiplegic patients being

more inactive and passive.

With negative feelings there seems to be a shift of activity

in the brain predominately towards the right hemisphere.15

In our study on trauma-exposed train drivers, upon trauma

memory, a relative increase of activity in the right hemi-

sphere was noted with SPECT.32 With procaine-induced

mental states negative emotions correlated positively with

left amygdala activation whereas positive emotions correlated

negatively with left-sided amygdala activation.33

In 24 women with PTSD, Metzger et al34 found that

right-sided parietal EEG activation during resting state was

associated with PTSD arousal symptoms.

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Achuff 35 notes in a review that there are two theories.

The right-hemisphere model proposes that the right hemi-

sphere is dominant over the left hemisphere for all forms of

emotional expression and perception. The valence model

suggests that the left hemisphere is dominant for positive

emotion (approach–appetite) and the right hemisphere for

negative emotion (withdrawal–avoidance). There are good

arguments to both models, and a vast literature is summarized

in Alves et al.36

However, there might also be an individual difference in

hemispheric activation in emotional arousal. Schiffer et al37

found a lateral shift to the right hemisphere in about 70% of

subjects who had been maltreated as children. In the other 30%

the shift was towards the left. The technique used in that study

was EEG during a neutral or upsetting memory. Those authors

concluded that there is a lateralization of emotional memory

that can be either right- or left-sided, such as other lateralization

qualities, for instance left- or right-handedness. We will return

to this subject discussing the importance of the lateralization

of emotions for the treatment suggested below.

The sympathetic and parasympathetic systems in fear memoryIn the autonomic nervous system the sympathetic system is

engaged in energy mobilization and gross motor activity while

the parasympathetic system is associated with restorative

and vegetative functions. These two branches are in constant

dynamic interaction as described by Thayer and Brosschot38 in

2005. It is suggested that the default reaction is the sympathetic

activation to novel stimuli, thus favoring safety activity such as

the fight or flight response. Thus, there is a dis-inhibition of the

parasympathetic system in the fear reaction, the tonic inhibi-

tion being restored afterwards. Such inhibition is dependent

on the prefrontal cortex, forming a top-down regulation. When

the prefrontal cortex activity is lowered there is a withdrawal

of parasympathetic inhibition, and this leads to an increased

sympathetic dominance, associated with defensive circuits.

Heinzel et al39 showed emotional pictures to a sample of

healthy subjects during functional magnetic resonance imag-

ing, and found a decreased signal in orbitomedial prefrontal

cortex. This suggests a decrease of the frontal tonic inhibition

in visually elicited fear reaction. The brainstem–midbrain is

implicated in the regulation of autonomic response by nuclei

as for instance locus coeruleus (noradrenergic). The amygdala,

which evaluates the positive or negative valence of external

and internal stimuli, activates the fear system upon perceived

danger. The hippocampus, as well as the amygdale, attaches

the fear reaction to new situations by associative learning,

reminding of the original danger.40

Kosten et al41 found increased 24-hour urine excretion

of adrenaline and even more pronounced increase of nora-

drenaline in nine Vietnam War veterans. Breslau42 reported

from an epidemiological sample that catecholamines

(noradrenaline, adrenaline, and dopamine) were elevated in

PTSD-subjects compared with controls without PTSD. Night

secretion of catecholamines was reported to be elevated in

PTSD subjects.43 However, Murburg et al44 found that basal

sympathetic nervous system functioning was not increased

in PTSD patients, and suggested that the increases of cate-

cholamines found indicated increased sympathetic reactivity.

Thus PTSD might be defined as an anxiety disorder with

a dysregulated balance between inhibitory and excitatory

impulses at trauma-trigger-related exposure. O’Donnell

et al reviewed the topic of the noradrenergic neural networks

and symptoms of PTSD.45 The reasoning in this paragraph

illustrates the need to activate both the parasympathetic and

the sympathetic systems during therapy.

Pathological fear memory – the flashbackPathological fear reactions are fear memories that are lacking

the safety signal in a situation that is not dangerous.46 Reaction

activates perceptions, autonomous reaction, and impulse to

act. This discord between environment, perception, and action

severely hampers the smooth regulation of mood, which is nec-

essary for functional interaction with the environment. A central

concept in pathological fear reactions is the flashback.

The term flashback originates from drug experiences

in which drug users reported spontaneous and fearful re-

experiencing of elements of the drug experience. This hal-

lucinatory experience can be present in different sensory

modalities such as auditory and visual hallucinations. In a

study by Yui et al47 of spontaneous recurrences to amphet-

amine psychosis, there were higher plasma norepinephrine

levels during the flashbacks. In a study of brain activity during

flashback after script-driven symptom provocation in PTSD

subjects, Osuch et al48 used script-driven symptom provocation

in patients with longstanding PTSD to elicit a fear reaction

that was studied with PET measuring cerebral blood flow.

They found a direct correlation between flashback intensity

and activity in the brainstem, areas associated with motor

control, complex visual/spatial cues, and memory. There was

an inverse correlation with prefrontal areas.

There are also findings in two studies of an altered

cortico-thalamic activity during the flashback experience.49,50

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Affective neuroscience and psychotherapy in trauma reactions

These changes in the cortico-thalamic loop suggest a focus on

internal perception during intense fear memory, the thalamus

being also a sensory gating area.

The fear memory with “de novo” quality can be presented

in several sensory modalities, but also fragmented or in only

one modality. This suggests that there could be only a sound,

a fragment of a scene, or a strong autonomous reaction, and

this is the way trauma memories might appear in clinical

states such as panic anxiety.

In summary, the key phenomenon of trauma-reaction

pathology – the memory disturbance with reliving episodic

memory – seems to be defined by an increased sympathetic

tone, a disinhibition of frontal control, a turning to internal

sensory perception, and an activation of cerebral networks

reminiscent of conditions at encoding. Such re-experiencing

memory can be as brief as short flashbacks but also longer

and more debilitating with prolonged flashbacks in intensive

anxiety states; it can even be perceived to last for days in

cases with trauma-related dissociative psychosis.

As far as we are aware there is no knowledge of the

brain being organized across our diagnostic categories in

trauma reactions, but rather that it works with continuously

balancing feedback systems in order to achieve adaptation

to the environment.

We conclude that there is a physiology of the traumatic

reliving memory that is important in treatment.

Changes following psychotherapyIn a review of functional neuroimaging, Linden51 concluded

from four studies with phobia and panic disorder that the most

consistent finding following successful cognitive behavioral

treatments was decreased activity in the limbic and paralimbic

areas. A study on eye movement desentization and repro-

cessing (EMDR) therapy was done by Pagani et al52 with

traumatized subjects from occupational hazards. The results

were that in post-treatment there was a normalization of a pre-

vious higher activity in medial temporal lobe, fusiform gyrus,

and primary visual cortex. Bryant et al53 showed that poor

response to psychotherapy was associated with greater bilat-

eral amygdala and anterior cingulate activation in response

to fearful faces. These findings indicate a change in frontal-

medial temporal lobe balance, implying that frontal control

of emotions is part of the beneficial treatment effect.

Reconsolidation of emotional memoryIn a seminal study by Nader et al54 it was described how

a consolidated memory became susceptible to change,

either by reinforcement or attenuation, during a short

time after retrieval. A similar window of memory change

(reconsolidation) was shown in humans with declarative

memory by Forcato et al.55 The importance of the theory

of memory reconsolidation is that it supports memory

transformation as a psychotherapeutic strategy. This

concept means that the original memory is not constantly

remembered in its initial form, but consists of layer upon

layer of modifying new experiences. When trauma reac-

tions develop into chronic states such as severe PTSD

the new memories are fear memories, thus deepening and

spreading the fear reaction, but with natural attenuation

the reverse is true.

Nadel and Moscovitch56 argue that the hippocampus

is activated in episodic memory retrieval leading to a

re-encoding. This means that reactivated memories are

made stronger while others fall into oblivion, and that

several short reconsolidations are more efficient than

one prolonged consolidation in creating stable episodic

memories.57

Monfils et al58 conducted an experiment with rats

where there was an extinction training in the time window

of reconsolidation after presentation of a conditioned

stimulus. Results showed that the conditioned fear response

did not reappear upon provocation, and the authors sug-

gest that a new – alternative or combined – memory trace

was formed. This memory trace was not associated with

a fear reaction.

For human learning, Forcato et al59 showed that a con-

solidated memory recalled by a reminder is open to the

addition of new information during a short time span until

reconsolidation takes place.

The motor reaction in fear reactionsIn rodents, the central nucleus of the amygdala projects

to the brainstem nuclei and to the hypothalamus, which is

related to passive expression of fear. In contrast, the basal

nucleus of the amygdala projects to the striatum, which

is involved in active anxiety-diminishing motor coping

strategies.60

Motor response is a central part of emotional memory,

and we hypothesize that motor planning and motor impulses

underway – but not being consummated – are a part of the

pathological fear response that might be related to differ-

ent aspects of pathology such as pain, restlessness, escape

impulses, and aggressive and self-aggressive impulses. In

Panksepp’s61 dual-aspect monism approach, he underscores

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the emotional action systems as being both experience and

action. Nardo et al62 showed that with PTSD following

occupational trauma there was a higher activity in the insu-

lar cortex as well as in the basal ganglia, suggesting both

increased awareness of autonomic arousal and increased

motor activation.

It is well known that a trauma in which the victim

is immobilized is often related to severe post-trauma

symptomatology. Could it be that immobilization leads to

the passive expression of fear with a high level of anxiety,

and that active coping motor activity during the traumatic

event leads to subsequent less severe later manifestations

of fear reactions?

In this paragraph we have underlined that there is a motor

component to emotions, and we suggest that the motor activ-

ity inherent in the emotional response is related to symptoms,

and must be addressed during treatment.

A manualized psychotherapy protocolFrom the emerging neurocognitive studies of emotion we

propose a set of treatment principles to form a manual-

ized protocol for affective psychotherapy. The exact tech-

niques may vary, leaving space for different theoretical

and practical orientations. The basis of this protocol are

the premises that: 1) episodic memory is also emotional;

2) emotions are a tripartite unity of perception, autonomic

reaction, and motor impulses (the PRM-complex); and

3) valence, intensity, and control are key aspects of emotions

to be treated.

The aim of the treatmentThe aim of the treatment in cases of dysfunctional fear-

memory reaction is to change the valence and the intensity

of the traumatic memory and to increase control of memory

retrieval. The goal of the treatment is to change a reliving

intruding memory into a more distant episodic memory.

The mechanism of the treatmentThe proposed way to change the traumatic memory is by

reconsolidation. The emotional memory must be accessed

and re-experienced: it is then in a labile state that is amenable

to change with for instance imaginal exposure, focusing

on the three aspects of the emotion (the PRM-complex).

Afterwards, it can be reconsolidated as a new memory that

does not produce fear reactions. It can also be supplemented

with a positive fantasy about the initial event, thus creating

associative links to alternative affective experiences.

The means of the treatmentThe positive and negative emotion must be activatedBoth the negative and the positive emotion must be

activated during the treatment session. Activating only

negative emotions is counterproductive, because it may

lead to a symptom rehearsal that will be consolidated in

the memory system as a new negative fear reaction. Thus,

it is imperative to start with the positive emotions. The

need to activate both negative and positive affects can be

associated with the lateralization of emotions in the brain.

We suggest that instructions that activate both hemispheres

of the brain help in arousing both negative and positive

emotions. Activities engaging sensory stimulation such

as movement, drawing, listening to music, specifically

looking at something, or following a moving object with

the eyes are such examples. Presumably they are active to

both brain hemispheres.

At first, positive emotions must be accessed. This is

needed because positive affect must be part of the new

memory to be produced during the session. There should

be no activation of negative affect in case positive affect

cannot be evoked. In such a case, a longer time and more

sessions must be spent to reach a positive affect. Activating

positive affect means increasing the parasympathetic tone.

This can be achieved by relaxation exercises: breathing

and meditation, safe-place imagery, perhaps walking on

a treadmill or bicycling on a spinning cycle. Also other

aspects of safety in the treatment setting are of importance,

such as stage of change process and preferences matching.63

Once activated, the positive emotion can be anchored in a

scene or image with focus on all senses. This means that

specific instruction can be given to note the sight, hearing,

proprioception, gustatory feeling, and total body sensation

in a state of safety and control. After this, instructions are

given to connect this positive sensory state with mental

clues of retrieval.

The emotional memory as a PRM-complex to be changedThe emotional memory is composed of sensory, autonomic,

and motor activations. In severe fear reactions, as seen in

flashbacks occurring in PTSD, there is a more pronounced

activation of motor areas in the brain. The emotional memory

is not seen as a depiction of an earlier event, but as a blue-

print for action, a script, a planned scene. This could be

conceived as a PRM-complex. With brief instructions, such

as taking a deep breath, the patient can be focused on the

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Affective neuroscience and psychotherapy in trauma reactions

inner experience of the negative emotional memory. This is

similar to Elman64 hypnotherapy with short inductions into

a state of focus on inner sensations. The proposed protocol

is then to: A) re-experience the event in vitro, ie, by mental

imagery, an inner film with focus on the sensory experiences;

B) experience a version with focus on autonomous reactions;

and C) experience a version with imaginal acting out of the

motor impulses, the inherent prepared act in the conjured-up

situations. These imaginal replays are done in an atmosphere

of safety and can be combined with instructions of focusing on

breathing, or by adding external sensory stimulation as well.

This results in a process with a combination of negative and

positive affects, the original event can finally be re-experienced

without fear, and the final outcome will be an emotionally less

disturbing memory. When this stage is completed there is space

for a new memory of the original events, and this is done as

imagination of how the original event should have been in a

positive fantasy. This is a repair fantasy that will be added to the

memories associated with the traumatic event. This protocol

with different versions of an event is close to the hypnodrama

protocol of “the way it was, the way it was not, and the way

it should have been” during imaginal exposure.65 Various

body–mind techniques, such as hypnotherapy, psychodrama,

EMDR, guided imagery, music therapy, drama therapy, dance

therapy, movement therapy, art therapy, can be part of an active

multimodal psychotherapy approach following the proposed

manualized protocol of affective psychotherapy.

This view of the emotional memory as a scene opens up

the use of the arts in the treatment. The nine muses of the

Greek goddess of memory all offer the possibility to express

emotional experiences through art. The use of the arts in

psychotherapy can be summarized as activating the “play

mode”, the ability to get into a memory and/or a fantasy

with emotional content, but still knowing that it has an “as

if ” quality. Play is suggested by Panksepp61 to be one of the

core emotional action systems.

ClosureAfter processing the traumatic exposure so that it is linked

less with negative associations but rather to positive alterna-

tives, there is a new task at hand. This is about the future.

In pathological emotional states there is often difficulty in

bringing to mind and imagining a positive expectation. But

expectations for the future can be seen as the memory of a

fantasy, which can be practiced. The client is asked to imag-

ine the future, for instance until the next session, and imagine

that things will go well. This fantasy is then experienced, for

instance as an inner movie.

Finally, there is time for the return of the positive feeling

in the relaxation or safe-place experience. After that comes

a short evaluation of the session, the client being in an adult,

competent position of cooperation and evaluation.

In summary, with this memory reconsolidation protocol

the aim is that there will be, in a setting of safety and control,

without a fear reaction, the following new emotional memo-

ries: A) the sensory experience; B) the autonomous reaction;

C) the motor program; D) a new alternative positive version;

and E) a positive future projection.

example 1, a single caseA boy aged 17 years comes to the clinic after referral

by the school social worker. His complaints are feeling

depressed and such somatic symptoms as fainting, nausea,

and breathing difficulties. He has at times visited a somatic

hospital where the examinations have not revealed any

pathology.

First visitOn the first visit the patient complains mainly about dif-

ficulties in falling asleep, severe nightmares, and frequent

day-time crying spells without having any hunch as to pos-

sible cognitive content or any memory associated with the

complaints. He comes with his mother who is also present

during all the sessions.

On the WHO-5 Wellbeing Index (WHO-5) he scored

48, indicative of a slight depression. In the Mood and Feel-

ings Questionnaire (MFQ) short version he reports a score

of 10, also indicating moderate depression.

In the treatment part of the session we focus on the situ-

ation of trying to fall asleep, and make a fantasy replay. It

becomes clear that he has a fear that keeps him in a state of

alarm. He practices calming and soothing techniques during

the session in order to be better able to relax at bedtime. He

also rehearses a future good falling asleep pattern while in

a play mode.

Second visitThree weeks later the patient returns for a new visit. Now

he says that after an initial improvement his state has dete-

riorated. He has increased feelings of hopelessness, more

severe mood swings, and increased suicidal ideation.

His score on the WHO-5 is 28, indicating more severe

depression. The score on the MFQ is 16, indicating severe

depression. He agrees to try affective psychotherapy and he

starts by making a mood map. This map depicts the present

interaction of emotional states as well as proposed changes to

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Högberg et al

achieve a wished for future well-functioning mood regulation.

A treatment plan of five sessions is designed.

Third visitThis is the first visit solely devoted to treatment. The patient

starts with relaxation and well-being exercises, and then

evokes the fear that hindered him from falling asleep. He

experienced a bodily sensation of stiffness and when this is

focused on he enters a memory related to negative family

relations at the age of 10. He explores those memories in

his mind, following the treatment protocol, and the nega-

tive emotional arousal gradually decreases. The movement

impulse being held back at the time was running, which he

now can experience in fantasy. He then makes a fantasy replay

of the way it should have been – having been consoled and

protected. Finally he re-enters in a state of relaxation and

well-being fantasy. The session is completed by an evaluation

that was positive. He is surprised at the appearance of those

episodic memories and of their strong emotionality.

Fourth visitOn the fourth visit 5 weeks later, after Christmas vacation,

he says that he wants to stop the treatment. He came only to

say thank you because now he feels well. He has no prob-

lem falling asleep, no anxiety spells, and no somatic com-

plaints. His score in MFQ is 0 and in WHO-5 92, indicating

good mental health.

Fifth visitAt a scheduled follow-up visit 3 months later he is still sleep-

ing well, had no somatic complaints, and no anxiety spells.

His score on the MFQ is 0 and on WHO-5 92. When asked

why he thought his mental status had improved, he refers

to the treatment given.

ReflectionThe results in this single case were good and showed the pos-

sibility of adapting the proposed protocol. We must, however,

caution that symptomatology is not always dissolved that eas-

ily. In this case, the presence of a safe person during the treat-

ment sessions might have added to the treatment effect.

example 2, a case seriesIn a case series of 14 suicidal adolescents it was found

that they presented a post-trauma reaction with suicidality,

insomnia, bodily symptoms, and disturbed mood regulation.66

They were treated according to the psychotherapy treatment

protocol presented in this article. Of the adolescents 13 out

of 14 had lost their severe symptoms within 4 to 20 treatment

sessions. The Global Assessment of Function was judged

before treatment, directly after treatment and at 22 months

post-treatment. The significant change towards normality

after treatment was still present at the 22-month follow-up.

Summary and prospectsThis paper has attempted to extract important aspects of

present knowledge in the neurocognitive science of emotions

and to apply these to the treatment of disturbing reactions

with negative emotional memories. We believe that this is

an emerging field and that clinical practice and affective

neuroscience can mutually interact to improve the treatment

of suffering individuals. Based on the theory of memory

reconsolidation, the approach presented focuses on changing

old emotionally negative episodic memories and on creating

new positive memories. It also hypothesizes that the motor

component in the emotional memory is central to pathology;

emotion and action preparedness being inseparable.

These ideas should be further tested. The manualized

approach presented, the treatment framework of affective

psychotherapy, is free to be tested and developed.

DisclosureThe authors report no conflicts of interest.

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